GPs may refer patients directly to Gender Identity Clinics (GICs). It is not necessary for GPs to first refer patients to another specialist service (e.g. a psychiatrist). This is important because until now most GICs in England have required patients to be referred by a mental health specialist.

Facial hair removal will be available on the NHS. The Interim Protocol describes facial hair removal as “essential treatment for MtF patients” (p.10). It is funded by NHS England, rather than CCGs (Clinical Commissioning Groups: these replace Primary Care Trusts). Patients are (in theory) guaranteed nine facial hair removal treatments: one test patch, and nine sessions. Funding can be sought for further treatments but is not guaranteed.

Hair removal prior to genital surgery will be available on the NHS. Funding for this service is provided through NHS England in a similar manner to facial hair removal for MtF patients.

Adult treatment is available to trans people from the age of 17. The Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust will continue to provide services in London, Exeter and Leeds for trans people under the age of 18, according to its own guidelines. This means that trans people aged 17 may choose between “adult” and “young people’s” services.

Breast augementation, facial feminisation surgery, lipoplasty and sperm/egg storage may be funded. Breast augementation will only be funded if “there is a clear failure of breast growth in response to adequate hormone treatment”. All of these procedures are funded by CCGs rather than centrally through NHS England, which means that GICs must apply to CCGs for funding. They will be funded (or not) according to CCG policy, which may vary.

Patients require only one assessment from a GIC team member in order to be referred for psychotherapy or speech therapy. This is important as it has the potential to speed up access to speech therapy and additional psychotherapeutic support.

Patients must recieve assessment from two GIC teammembers in order to recieve hormone therapy. This is important because until now, some GICs in England have required assessment from more than two team members. Conversely, it reinforces the position of those clinicians who argue that two opinions is necessary before treatment can begin.

12-24 months of “real life experience” is required prior to the provision of genital reassignment surgery. This is important because it means that patients can (in theory) access genital surgery within a year, in line with WPATH guidance. However, it is likely that clinics will continue to demand at least 2 years of “real life experience” prior to surgery.

A wait of at least 6 months is necessary prior to the provision of chest surgery for FtM patients. The guidance on this is somewhat vague, which should allow flexibility but may be exploited by more conservative GICs. The Interim Protocol states that patients who qualify for chest surgeries “may have engaged in a social role transition” (emphasis mine), and that a referral will “typically” be offered “around 9-12 months, but no less than 6 months, after the patient’s first consultation”.

Surgical providers are supposed to inform primary care staff (i.e. GPs and nurses) of procedural details and post-operative needs. We’ll see how this one pans out in practice!

Overall, this Protocol should result in a broad improvement in transition-related services for trans people living in England and Wales. If all goes to plan, more services will be available to more people, who will have to do less waiting for them! I offer a more in-depth discussion of these changes – and comparisons to the Scottish Protocol – here (please note that there have been changes since I wrote that post – e.g. GPs should now be able to directly refer to GICs, and facial hair removal should be provided on the NHS in England and Wales, just like Scotland) .

However, GICs may yet resist some of the measures in this document. The protocol was meant to come into force for all trans patients access transition-related services from 1 October 2013, so now is the time to hold medical providers to account.

A review of England’s draft protocol for gender dysphoria services by CL. You can read a copy of the draft protocol here, respond to the survey here, and read my own analysis here.

—

Following the lead of an information note published by the department of health, the draft protocol confirms and compounds the problems of treating gender dysphoria on the NHS. It would at least mostly standardise treatment protocols across England, burdening everyone with the same problems: We’re all in this together, right?

The Gender Services Clinical Reference Group is aiming to implement standardised service provision by April 2013 and has given interested groups until September 30 to respond. GIRES has responded, as has Terrence Higgins Trust’s Trans* Women’s Sexual Health and Wellbeing Group, whose submission I contributed to. Our issues with the Department of Health’s Information Note are seen again here, and I’d like to focus on those in particular: the framing, tailoring and requirements of treatment.
Framing Gender Services Treatment

A problem in the protocol that has carried over from the information note and current practice, is the framing of gender dysphoria treatment as the property of psychiatric specialists. Even in updating the condition being treated to ‘gender dysphoria’ from Gender Identity Disorder, which explicitly frames the problem as one with our gender identities rather than our physical characteristics and the dysphoria resulting from them, the protocol places gender dysphoric people under the care of “a mental health professional (eg. psychiatrist or psychologist) who specialises in transsexualism/gender dysphoria and has general clinical competence in diagnosis and treatment of mental or emotional disorders.”

The logic behind this in the current protocol is not forthcoming. Perhaps it is because there’s a likelihood of additional mental health issues due to the stress of dysphoria. Realistically, it’s because dysphoric people have always been treated as mentally ill, and tradition has kept us under the exclusive care of psychiatrists.

Assessment is a large part of the GICs role: confirming that we have Gender Dysphoria and are not merely deluded about our gender identities. Gender Dysphoria strong enough to necessitate transition is rare, certainly, and doctors are warned to be warey of ‘Zebra diagnoses’ (as House of God, the inspiration for ‘Scrubs’ described them). That is, when you hear hooves, think horse, not zebra. That’s sensible advice, but if you’re in southern African plains, thinking Zebra first might not be so unreasonable. In this case, if someone is distressed by their assigned gender and sexed body, identifies strongly as another gender and feels relief when living as that gender, a diagnosis of ‘trans*’ is the most likely answer. Trusting this principle would rob the GICs of hours of questions about your childhood hobbies and masturbatory habits, but it would free up a lot of unnecessary appointments.

Scotland has already moved away from the complete ownership of Gender Services by mental health teams, allowing patients to self refer to a GIC. This saves an appointment with a GP, one with a community mental health team and allows direct access. For those who need a diagnosis, removing these two stages of waiting, where ignorance or prejudice can delay or waylay a patient, can get them that diagnosis quicker. Given the burden on admin staff and funding, a time, appointment and money saving move like that is far better than the protocol’s recommendations.

Tailoring Service

The introduction to the protocol claims that it is ‘informed by the 7th edition of the WPATH Standards of Care’ – sadly, it isn’t based on them. Some key recommendations from the 7th SOC were: HRT could be prescribed without RLE and one assessment, Lower Surgery required only one year of RLE (rather, one year of HRT). None of those recommendations are followed here, so the role of the 7th SOC’s ‘informing’ is not apparent. As Ruth points out, this is essentially just the existing Charing Cross treatment.

The protocol makes references to giving patients time to consider other options, other approaches, time to reflect and, of course, the RLE’s time to consolidate. There can be great value in this and many people seek the GIC to explore and understand their gender identity. Chances to really assess their history, feelings and situation can be very valuable. A friend in this situation said that her diagnosis brought her great relief and confirmation of her feelings.

For others though, this is unnecessary. Many others will have thought, reflected and considered extensively, almost exclusively at times, before seeking a GIC: they know who they are and what they need. For them, the numerous stages to access a GIC, double assessments and arbitrary RLE periods merely delay them, take up clinic time and appointments and cause additonal frustration as they wait for their treatment.

Clinics shouldn’t be forcing surgery on everyone at the first appointment, but the slowest common denominator approach is hardly ideal either, and unnecessary, arbitrary waiting is positively detrimental in many cases.

Requirements

Despite the 7th SOC’s ‘informing’ of the protocol (perhaps they were low on coasters?), RLE remains a key feature of the proposed gender services. The protocol is unclear about RLE requirements for HRT, but indicates that full HRT can be prescribed ‘Dependent on whether an individual has socially transitioned in the sense of living full time’ or is likely to ‘do so immanently’. Top surgery needs a year of RLE, lower surgery needs 2 years.

The problems with this are numerous:

It’s arbitrary. There are medical reasons for a year of HRT for lower surgery, but not for living full time in role.

Requirements of being employed have nothing to do with a stable, well founded gender identity.

Whilst individuals vary greatly, some people have considerably more difficulty being read as their gender prior to HRT, and AMAB people are more likely to recieve certain forms of harassment if people read them incorrectly. Forcing people into public facing roles to get the treatment they need puts them at direct risk of violence, harassment and discrimination.

What ‘real life’ is being experienced? From my own and others’ experience, I know that living full time as a woman pre HRT is vastly different to being full-time after a year on HRT. The near daily abuse and marginalisation, with incumbent stress, is not the real life I’m experiencing now, but was a feature of living as a woman who was visibly trans*. The RLE required is entirely unrepresentative.

For all the regional variation and obfustication, the 2 years of RLE for surgery is well known, and patients work to it. The lengthy requirement can prompt patients to ‘start the clock’ running on RLE long before they are ready. Who knows how much suffering has come from that, or from knowing that no help will come before an arbitrary deadline?

Patients remain on the GIC’s book during this period: the aforementioned zebras get called in for appointments to needlessly check that they’re still serious, then sent away to wait another 5 months. This takes up appointments that could help patients who are less certain of their needs.

Overall, this protocol standardises existing Charing Cross treatment, which is already behind the times in not adjusting to WPATH’s SOC 7, and seems particularly inadequate when compared to the updated Scottish protocol. Most worryingly, its requirements standardise the appointments that add to the waiting times, administrative burden (which currently means Charing Cross are taking 2-3 months to send appointment summaries) and sense of disempowerment that service users experience. With multiple screenings, assessment and ‘time for reflection’, it is particularly unsuited to those who have a clear understanding of their identity and wish to proceed, and who have thought over their option extensively prior to seeking a referral. If this protocol is to last for any significant time, it will hold service users to standards that are already inadequate – If the next update will last, we need to fight for a protocol that truly moves treatment forward, so make sure to give your views in the protocol’s survey.

The big news from Scotland today is all about gay marriage. But last week, the Scottish government quietly unveiled an equally important move.

The new NHS Scotland Gender Reassignment Protocol will have a massive impact upon those who seek a medical transition. It dramatically cuts the time required for “real life experience” prior to surgery, confirms the necessity of contested interventions such as hair removal for trans women and chest surgery for trans men, enables teenagers to begin transition from 16, and – crucially – reinforces the right of trans people to refer themselves to Gender Clinics.

Some background
Last year saw the publication of the latest edition of the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC). This seventh edition of the SOC saw a number of important changes that acknowledged critiques from trans communities as well as clinicians, leading to a focus upon gender variant identities and experiences in terms of diversity, rather than pathology.

Treatment is individualized. What helps one person alleviate gender dysphoria might be very different from what helps another person. This process may or may not involve a change in gender expression or body modifications. Medical treatment options include, for example, feminization or masculinization of the body through hormone therapy and/or surgery, which are effective in alleviating gender dysphoria and are medically necessary for many people. Gender identities and expressions are diverse, and hormones and surgery are just two of many options available to assist people with achieving comfort with self and identity. (p.5)

Thus, transsexual, transgender and gender non-conforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatments are available. (p.6)

This emphasis upon individual difference and patient agency differentiates this seventh edition of the SOC from previous editions published by both WPATH and its predecessor, the Harry Benjamin International Gender Dysphoria Association. The change follows decades of lobbying from trans activists, academics and progressive professionals. We’ve gone from a world where post-doctoral researchers who happened to be trans – such as Virginia Prince – could publish research only with the approval of cis clinicians, to a world in which trans professionals like Stephen Whittle are setting the agenda.

Competing guidanceWhen WPATH speaks, medical providers don’t necessarily listen. Trans people are often diagnosed according to criteria set out guidance such as the American Psychological Association’s Diagnostical Statistical Manual of Mental Disorders (DSM), which treats us as mentally ill. Gender clinics in the UK often follow previous editions of the SOC, which encourage a patronising, controlling approach in practitioners.

For instance, a recent Freedom of Information request revealed that Leeds GIC “…follows the stages laid down within The Harry Benjamin International Standards of Care (this differs from the WPATH guidance), as we believe that hormone treatment is best undertaken after real life experience has begun…“: i.e. the clinic is relying upon outdated guidance, under which patients are forced to go “full-time” for some time before they are prescribed hormones. This will clearly cause difficulties for individuals who have trouble passing as cis without hormone therapy, and may leave them open to harassment or violence.

Even less regressive GICs in the UK currently do not comply with with the most recent edition of the SOC. This can be seen in the imposition of binary ideals of gender, the absence of treatment protocols for most trans adolescents, and a “real life test” of at least two years before requests for surgery are considered (as opposed to the 12 months recommended in the new SOC).

Of course, any revision of national medical practice takes time, particularly within a public body such as the NHS. Changes to the NHS care pathway in England and Wales are currently under discussion. Moreover, hormone regimes for teenagers are currently being trialled in London. I don’t know enough about the situation in Northern Ireland to write about what’s happening there.

It is against this backdrop that the new Scottish protocol has been introduced.

NHS Scotland Gender Reassignment Protocol: the headlinesThe new Scottish guidance has been shaped by trans activists working with key figures within Scottish equality bodies and NHS Scotland. It won’t have an immediate impact upon the availability of services, with implementation being a long, complicated process. However, it is historic in that the published care pathway clearly empowers trans patients in a number of ways.

The Scottish Transgender Alliance highlight a number of important points from the protocol (emphasis mine):

people can self-refer to NHS Gender Identity Clinics (GICs) in Scotland.

that psychotherapy/counselling, support and information should be made available to people seeking gender reassignment and their families where needed.

that two gender specialist assessments and 12-months experience living in accordance with desired gender role are needed for referral for NHS funded genital surgeries and that arrangements for delivering agreed procedures are under review with the objective of ensuring that an effective, equitable and sustainable service is implemented.

only one gender specialist assessment is needed for referral for hair removal, speech therapy, hormone treatment and FtM chest reconstruction surgery and that these can take place in an individualised patient-centred order either prior to starting the 12-month experience or concurrently to the 12-month experience.

that, in addition to access to genital surgeries, access to hair removal is regarded as essential to provide for trans women and access to FtM chest reconstruction is regarded as essential to provide for trans men.

that surgeries which are not exclusive to gender reassignment, such as breast augmentation and facial surgeries, continue to need to be accessed via the Adult Exceptional Aesthetic Referral Protocol but there will be a more transparent and equitable panel process for making funding decisions in such cases.

that young people aged 16 are entitled to be assessed and treated in the same manner as adults in terms of access to hormones and surgeries.

that children and young people under age 16 are entitled to child and adolescent specialist assessment and treatment as per the relevant section of the WPATH Standards of Care. NOTE: at the time the protocol was created the staffing of a specialist Under 16s service at the Sandyford GIC in Glasgow was uncertain but it now looks likely that there will be a sustainable Under 16s service provided at the Sandyford GIC in Glasgow and this part of the protocol will soon be updated.

As the Scottish Transgender Alliance note, this protocol isn’t perfect, but it does represent an important step forward. If the protocol is properly implemented, trans people will no longer be forced to spend months (or even years) fighting for a referral, before waiting even longer for treatment as a GIC patient. Trans people will be able to access vital interventions such as hair removal on the NHS, and should be able to access proper counselling and therapy services.

A personal perspective
If a protocol such as this had been in place in England when I came out as a teenager, I could have gained a referral (or even referred myself!) to a GIC at the age of 16. Even with the massive waiting list for the GIC, I might have been on hormones at 17, and had surgery at 18. I wouldn’t have had to undergo anything like so many painful laser hair removal sessions, and those that I did undergo would have been paid for by the NHS.

Instead, my first GIC appointment was at the age of 19. I didn’t go on hormones until I was 20 (causing all kinds of havoc with my university grades during my final year as I underwent a second puberty) and had surgery shortly before my 22nd birthday. I paid for several laser hair removal sessions privately. One day I hope to afford a few more, as I never finished that particular treatment.

And I’m one of the lucky ones.

The futureI can’t really understand why this isn’t already all over the LGBT press, let alone the trans blogosphere. It’s a deeply important development.

The progressive nature of the new Scottish protocol provides a positive precedent for the rest of the UK. We can only hope that NHS protocols for England and Wales and for Northern Ireland follow suit. In the meanwhile, trans activists throughout the UK could do well to pay close attention to the situation in Scotland. The success of organisations such as the Scottish Transgender Alliance provide important lessons for the rest of us.

The following was written by Louis, who recently experienced an appointment with “Dr Jiff” that unfolded pretty much as outlined.

“But let me tell you, this gender thing is history. You’re looking at a guy who sat down with Margaret Thatcher across the table and talked about serious issues.”
– George H. W. Bush

One morning, as I awoke from anxious dreams, I discovered that in my bed I had been transformed into exactly the same body as I had been the night before.

Examination of my whole organic structure proved this to be true, and as my mother greeted me normally in the kitchen, my feeling of de-centralised horror was crystallised. Most people, upon waking to find themselves the same, would find reassurance in the stability of their own identity – unchanged by the nights stargazing. To the average man or woman, the roaming of a well-gendered mind at rest is a pleasure. I, however, on that morning, realised that my unprecedented disquiet was the beginning of something. I was right. I have not been quite at home with myself since.

Psychology today is a noble hobby, halfway between a humanity and a science. I tend to lean towards the side of art.

On the 9th December, 2010, I find myself sitting in the office of Dr Jiff in University Hospital Coventry. It’s the psychiatric clinic. I’ve spent half an hour waiting outside, before being beckoned, with a smile, into this room, where I am to give the performance of my life. My part: Myself, as the National Health Service wants to see me. The office is large and sparse, with high, grey windows and navy blue carpet. It’s warm, however, and my chair is comfortable. Not a couch, but a plain lavender seat by the doctor’s desk. Dr Jiff himself is something of a surprise. After all I’ve heard, here is a man in his twilight years: rotund, moustached, with yellow sweat patches under his arms. A fair tie, mind you – M&S perhaps.

He has an affable face, and is delightfully frank in all things… though as usual for a psychiatrist, his eyes are mirrored walls. This is our first meeting. As I write, I expect many more: my performance this day is a surprising success.

To begin to understand the nature of my madness, I would first have to explain what madness actually is, in a social context at least. I’m sure you have your own ideas on the matter, but here’s my take on the state of things. Madness is a state of mind which society as a whole (or perhaps the ideal that society projects of itself, and never seems to actually get to) finds to be outside the bounds of “normal”. Sometimes madness is considered genius. Sometimes geniuses go mad. More often than not, madness is considered a rather dangerous or undesirable thing to have around. The more cutting amongst you may have noticed that I didn’t define what “normal” is. That’s because I truly have no idea.

In Psychology and Psychiatry, different kinds of madness are categorised and given different names. The name for my particular type of madness is Gender Dysphoria. It has an average occurrence, according to the NHS, of about 1 in every 4000 people in the UK – though it is important to note that these are only those individuals seeking treatment. Estimates have been made suggesting that 1 in every 1000 people may experience gender dysphoric feelings, or even 1 in every 120. Some psychiatric organisations have suggested that there are perhaps 500,000 gender dysphoric people in the UK, and 10,000 who have successfully asked for, and received, treatment. Statistically speaking, you’ve probably met at least 3 people with some level of gender dysphoria within the last 5 years of your life. Whether or not you were aware is a moot point.

The treatment of my disorder is seen with some contempt by the general populace – it requires the breaking of ancient rules of civilisation. This sounds more exciting than it really is. In day to day life, I’m perpetually astonished by how seriously people take gender labels, and how violently they will react against those individuals who wish to put their hand up halfway through the lesson, and say “Excuse me, I think you got that bit wrong.”

On the 19th of August 1992, a gender dysphoric person was removed surgically from its mother’s stomach and placed (screaming, purple and bloody) into the world, possessing all the appearance of female genitalia. Because of this, a somewhat tenuous, but deeply historic and traditional, social categorisation was made, and it was assigned the gender role of “female”. However, the gender label which it now identifies with, if it has to at all (and that is a whole other debate), is “male”. Some people interpret this in the following way:

“She wants to be someone else” OR “She wants to be a man.”

A gender dysphoric person find this degrading and frustrating. As far as they are concerned, they have always been the same person, and will always be the same person, in one form or another. I summarise the following:

“He is a man, and if society wishes to hang so much meaning and status on gender pronouns – a figment of language no less – then it can at least have the decency to let people identify themselves, rather than thrusting identity upon them at a stage where they can’t argue back.”

Dr Jiff’s office, on the 9th of December, is a pleasant change from the usual hostility. To begin with, he has assured me that there are “unlikely” to be any problems in my referral. I explain the issues I have had when trying to achieve this in the past, and he shrugs off the ignorance of some in his profession with a simple:

“Some people just don’t go to enough conferences.”

Then:

“Do you masturbate?”

(Don’t tell me that wouldn’t knock you off balance a bit.)

“Yes.”

“Any particular fantasies?”

“Hmm.” I pull the face which I always pull when planning to politely lie. “No, just generic men.”

(Really, I have an imagination.)

“How do you identify – put into words?”

“Gay male, polyamorous.”

“Do you dream in colour or black and white?”

“Colour.”

“How do you place yourself within your dreams?”

(I want to say ‘the victim’, but I don’t.)

“Omnipresent.”

“And male or female?”

“I don’t see.”

“Any suicidal tendencies?”

“Nothing unusual. I saw a counsellor, it’s all in my notes and over with.”

And so on.

This stream of banal, sometimes cryptic, often probing questions, will determine the course of the rest of my life. In the end I “perform” so well that I achieve the referral and more: a fast track to a new clinic, with treatment as good as guaranteed in 3 months. The gatekeeper has been defeated. Apparently, the land of maleness is mine for the exploration, chatting-up, styling, drawing, eating, sucking, dressing, drinking, writing, injecting, rubbing, wanking, fucking, and taking. And the clothes. I’ll be able to wear a pair of trousers on hips that aren’t just-too-wide, and a suit tailored to fit a new figure – simple pleasures hard won. Why choose soft curves when you can have hard lines? I know which I find easier to follow. But I digress.

“What do you know about the surgical options?” Doctor Jiff asks.

“First you have to ‘live the life’ for 2 years.”

“Yes that’s right, how long’s it been for you now?”

“2 months. Facebook proves it.”

“Good. And what were you considering?”

“Phalloplasty looks generally crap. I want top-surgery though.”

“Yes. The success rates for breast reduction and removal are excellent. How big are your boobs?”

(I can’t describe the impact of words like ‘boobs’ leaving this man’s lips.)

“Small.”

“Well it will be a question of finding the right surgeon, but I can help you.”

“Thanks.”

“Phalloplasty, though, is a tricky one. In 2 years time when you’re eligible, things may have changed completely, but at the moment it’s a poor sport. What you really want is to be able to feel and to experience, which as things stand in the field is not particularly attainable, so unless you suddenly become desperate for a penis, it’s worth avoiding for now. I mean, can you have a really good orgasm with what you’ve got?”

“…Yes.”

“Then that’s good, and anyway, there are things you can do with a strap-on, especially anally, that just can’t be done by natural men.”

(It’s only after I leave the room that it occurs to me to laugh and laugh.)

The question of my sexuality is only mentioned in passing. I have heard several, interesting viewpoints on it. My good friend L___ was rather surprised when I suggested that there was any problem. “But 80% of the female population are straight,” he argued, “So surely 80% of transmen are gay? It’s just logic.” I thanked him for this excellent piece of reasoning.

Others, however, have been less supportive. The first psychiatrist I saw to try and obtain a referral was quite obstinate in her belief that a transman couldn’t possibly be gay, because all transmen must surely be lesbians who just couldn’t face up to their sexuality. “I like anal sex,” I told her, just for the hell of it. She didn’t appreciate that. Of course, there lies another minefield of debate: my under-eighteens counsellor pointed out that with my total lack of sexual experience of any kind, how could I possibly know what I was attracted to? This, to me, seems like a rather foolish question, and leads me to assert a rather controversial fact:

Nobody knows a person as well as they know themself.

That point made, it is interesting to note the breadth of reactions that a trans or gender dysphoric person may receive in their exploration of this idea. Imagine meeting someone you have known since infancy for coffee. The two of you make small talk and enjoy each other’s company, then out of the blue, your friend tells you that they have to say something important: they are not really brunette at all, they are actually blonde. To the evidence of your own eyes, this is ridiculous, and you say so. No, they explain, the brown is dye. I’ve been covering this up for my whole life.

Of course, hair colour is a somewhat less mind-bending issue than gender, but the premise is similar. Imagine the same conversation, but instead your friend reveals that they are homosexual. This is slightly more controversial. To someone like me it doesn’t matter at all, but of course to many people, this is a genuinely world-altering piece of information. Now, imagine your friend putting down their coffee cup, and telling you that they are actually the opposite gender.

Imagine walking away with that information in your mind.

Surely you know them better than that? Don’t you?

If you need to stick a label on them to understand them, do you really know them at all?